Basic Information
| Provider Information | |||||||||
| NPI: | 1124082250 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650859 | ||||||||
| Address2: | DEPT 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097476240 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775555302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097721221 | ||||||||
| FaxNumber: | 4097721224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 047596 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 41738 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | T5325 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 000921181E | 05 | GA | MEDICAID | 989896 | 01 | GA | BCBS | OTHER |